disinfection and c.difficileinfection 779
feedback each month on fluorescent marker removal and culture results. Individual EVS staff members and their supervisors received feedback on daily and postdischarge cleaning based on fluorescent marker removal. For hospitals with limited improvement in cleaning or whose performance waned after initial improvement, additional meetings were held with infection control personnel, EVS supervisors, and hospital administrators, and additional education was provided to EVS personnel. For the 8 control hospitals, no feedback or education were
provided. In addition to the baseline cultures, postdischarge cultures from CDI and non-CDI rooms were collected during a 1-month period between 4 and 9 months after collection of the baseline cultures.
Outcomes
The primary outcome measure was the incidence of HO- HCFA CDI. Secondary outcomes included (1) thoroughness of postdischarge cleaning of high-touch surfaces in CDI and non-CDI rooms, (2) thoroughness of daily cleaning of high- touch surfaces in CDI rooms based on fluorescent marker removal, and (3) effectiveness of disinfection of CDI and non- CDI rooms based on postdischarge cultures of high-touch surfaces for C. difficile.
Microbiology
Clostridium difficile was cultured on selective media as pre- viously described.4 Clostridium difficile was confirmed on the basis of typical odor and appearance of colonies and by a positive reaction using C. difficile latex agglutination (Microgen Bioproducts, Camberly, UK).
Data Analysis
Based on HO-HCFA CDI incidence of ~6 per 10,000 patient days (1,068 cases and 1,683,928 patient days) in the study facilities in 2009, we estimated >95% power to detect a 25% reduction in the incidence of HO-HCFA CDI and 70% power to detect a 15%reduction. The incidence ofHO-HCFACDI for individual hospitals and on average for control versus inter- vention hospitals was graphed for the 1-year periods before, during, and after the intervention. For each of the control hos- pitals, May 1, 2013, was chosen as the start of the year for comparison to the intervention period. A linear mixed model was used to compare CDI rates in the intervention and post- intervention periods for control and intervention hospitals, estimating the interaction effect of intervention versus no intervention and time with a random hospital effect. No other covariates were included in the linear mixed model because it was assumed that randomization would balance other covari- ates. Additional nonlinear mixed models were used to assess the effect of the intervention on fluorescent marker removal, looking at marker removal from postdischarge cleaning in CDI and non-CDI rooms and from daily cleaning in CDI rooms.
Tests of proportions were used to assess reductions in the per- centage of rooms with positive cultures in the intervention arm. Data were analyzed using R 3.2.2 with lme4 and lmtest packages.17
results
Figure 1 shows the percentage removal of fluorescent marker from high-touch surfaces for individual intervention hospitals and on average. The intervention resulted in a significant increase in fluorescent marker removal in CDI and non-CDI rooms that was sustained during the intervention year. For cleaning postdischarge in CDI and non-CDI rooms, the aver- age percentage of marker removal increased from 63% (1,641 sites with marker removal of 2,624 total sites in 235 total rooms; range, 23% to 74% for individual hospitals) to 82%
figure 1. Removal of fluorescent marker from surfaces after postdischarge cleaning of Clostridium difficile infection (CDI) and non-CDI rooms (A) and after daily cleaning of CDI rooms (B) from 7 intervention hospitals at baseline and during the intervention year. The thick line shows aggregate mean values for marker removal for all sites assessed and the thinner lines show mean values for the individual intervention hospitals. Abbreviation: Q, quarter of the study year.
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